Or i gi nal ar t i c l e

Attitudes to and knowledge about oral health care among

nursing home personnel an area in need of improvement
Inger Wa rdh
1
, Margareta Jonsson
2
and Maude Wikstro m
3
1
Karolinska Institutet, Department of Dental Medicine, Huddinge, Sweden;
2
Public Dental Health, Jo nko ping County Council, Sweden;
3
Sahlgrenska Academy, Go teborg University, Sweden
doi: 10.1111/j.1741-2358.2011.00562.x
Attitudes to and knowledge about oral health care among nursing home personnel an area in need
of improvement
Background: In 1999, a dental reform became law in Sweden that regulated both dental care to
dependent individuals and training in oral health care for nursing home personnel. Substantial resources
have been channelled into these efforts, but the outcome of these efforts has not been evaluated. The aim
of this study was to explore attitudes to and knowledge about oral health care among nursing home
personnel more than 5 years after the law was adopted, that being 2005.
Methods: A total of 454 individuals employed at nursing homes answered a questionnaire of 16 multiple-
choice items concerning attitudes to and knowledge about oral health care.
Results: Eighty-nine per cent considered oral health care to be an important part of good nursing. The
answers indicated problems, however, when it came to its implementation and knowledge, and 35% stated
that they had had no formal education in oral health care.
Conclusions: Despite generally positive oral health care attitudes, it is important that oral health care
education is available to and made of interest for all nursing home personnel, especially in light of the
increase in number of natural teeth and frequency of crowns and bridges among dependent elderly.
Keywords: education, nursing homes, oral care.
Accepted 17 July 2011
Introduction
The proportion of elderly people in the popula-
tion is increasing rapidly. By 2000, there were 69
million people over the age of 80 in the world,
and there are estimated to be 377 million by
2050.
1
The proportion still having their natural
teeth in their old age is also increasing. Hugoson
et al.
2
showed that the proportion of edentulous
80-year-olds had decreased from 56% in 1983 to
3% in 2003 in the Swedish county of Jo nko ping.
In a Norwegian study
3
on oral health status of
elderly residents living in nursing homes, the
frequency of edentulous participants decreased
from 71% in 1988 to 43% in 2004. In the den-
tate residents, the number of natural teeth and
the frequency of crowns and bridges had
increased. A recent study in Sweden revealed that
the edentulous rate among dependent home-
dwelling elderly was 32%, about 8% of whom
had osseointegrated implant bridges.
4
This
development is undoubtedly positive, but it also
constitutes a challenge to the nursing home per-
sonnel when the elderly residents are in need of
support with their daily oral health care.
Today, it is known that poor oral health condi-
tions have a negative impact on general health and
quality of life in older adults.
5
One of the WHO
priority action areas is, therefore, oral health
improvement amongst the elderly.
6
In 1999, dental remuneration was regulated by
law in Sweden, and the legislation also regulated
dental care for dependent elderly individuals. It
stated that these patient groups should have access
to:
an oral health care assessment in their home/
residence, free of charge,
basic dental care at subsidised rates and
nursing home personnel who are trained in oral
health care.
2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787e792 e787
Usually, a dental hygienist performs the oral
health care assessment. Basic dental care can in-
clude scaling, extractions, llings and adjustment of
dentures,
7,8
scaling and plaque removal. The
nursing home personnel should be offered training
in both theoretical and practical oral health care
once a year. This training is also usually given by a
dental hygienist.
Substantial nancial resources have been chan-
nelled into these efforts since the law was imple-
mented, but the outcome of the efforts has not
been evaluated. The aim of this study was to
explore the attitudes to and knowledge about oral
health care among nursing home staff more than
5 years after the law was adopted 2005. It was
part of a quality insurance project for nursing home
work.
Material and methods
The personnel at 12 nursing homes in the county of
Jo nko ping and the city of Go teborg, who had had
access to the oral health training programme for
nursing home personnel included in the Swedish
dental reform, were invited to participate in the
study. A total of 630 nursing home employees,
working at the nursing homes on a daytime sche-
dule, were invited to participate. The nursing
homes were selected as representing different
geographical areas, community sizes and types of
facility. The number of beds at the nursing homes
varied between 25 and 90. In Sweden today, many
nursing home residents have dementia or another
serious illness, because the ofcial policy is that
when elderly nursing home residents deteriorate,
they are not to be moved to other housing. Most
nursing homes have special units for residents with
dementia.
The questionnaire used in the study included
questions on gender, working experience, profes-
sion and earlier oral health care training, as well as
16 multiple-choice questions on attitudes to and
knowledge about oral health care. The question-
naire concluded with one open item for free com-
ments about oral health care work. The questions
were selected from two previously validated ques-
tionnaires.
9,10
The selection process included a
discussion how to choose the most valuable ques-
tions concerning attitudes to and knowledge about
oral health care among nursing home staff. The
discussions were held with a reference group,
consisting of ve nursing home employees who
were not participating in the main study, led by
author MJ. The nursing home personnel were
informed about the study, both verbally and in
writing, before inclusion. The local handling of the
questionnaires was left to the nursing home man-
agers.
Data analysis
The quantitative data were presented in total
numbers or frequencies. The qualitative data were
content analysed
11
by reading the written com-
ments and seeking meaning units (a group of words
or statements that bear the same central meaning).
These meaning units were then sorted into catego-
ries, which represent a group of contents that
shared a common denominator. The categories
were founded in the data by a selection of
descriptive text quotations.
Results
A total of 454 nursing home personnel (72%)
agreed to participate in the study. Six were regis-
tered nurses. Thirty-two per cent had been working
for more than 20 years in nursing and 5% for
2 years or less. Sixty-ve per cent of the nursing
home personnel answered that they had received
formal training in oral health care as part of their
basic education and/or during their employment.
Eighty-eight per cent had an appointment for a
check up at a dental clinic themselves once a year.
Almost all the respondents stated that they gave
oral health care to one or more of their residents
every day, and 89% considered oral health care as
an important part of good nursing. Seventy-seven
per cent of the respondents were of the opinion
that the residents would tell them when they were
in need of help with their oral health care man-
agement.
Tooth brushing was considered by 60% to be a
troublesome activity in nursing home care (Fig. 1),
and close to 80% answered that the greatest
obstacle to overseeing oral health care was that the
residents were not cooperative (Fig. 2). More than
half of the participants were of the opinion that a
persons teeth will fall out in old age whether or
not they are well taken care of (Fig. 3).
With regard to questions related to oral health
care, the majority, 94% of the respondents, an-
swered that uorides strengthen the teeth; 70%
were aware that dental plaque, in combination
with sugar consumption, was a reason for the
development of caries. The most common reason
for gingivitis seemed to be less well known. Forty-
seven per cent answered that they brushed more
cautiously when the residents gums were bleed-
ing. Thirty-six per cent were of the opinion that a
2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787e792
e788 I. Wa rdh et al.
dental prosthesis could be left in the oral cavity
during the night if the residents so wished.
The question about what type of education or
help from the dental team that would best con-
tribute to improving the residents oral health care
had an internal drop out of 16%. Of those who
answered the question, 40% thought that more
time would be the most important factor. Twenty-
ve per cent considered help from the municipal
dental team preferable, 21% practical oral health
care training and 13% favoured theoretical train-
ing. Sixteen per cent of the participants, or 75
participants, gave free comments on oral health
care work. The qualitative content analysis showed
that the oral health care work included some
common dimensions, or categories, although we
did not rank them.
The rst category was Uncooperative residents:
The most difcult are persons that refuse to open their
mouth for their carers, and do not want help or think
it is unnecessary.
The second category was Need of oral health care
education:
Even the nursing staff notices bad oral health care
work. I think it is good that they (the dental hygien-
ists) come and teach us how to do this because there
are those who do not know anything about what to
do.
The third category was A good reform:
The elderly have much better teeth due to the edu-
cation about how important it is to care for their teeth,
even if there are things to be improved. There is lack
of time but the reform is a fantastic advantage for the
elderly.
0
10
20
30
40
50
60
70
Hairwashing Feeding Changing diapers Toothbrushing
Figure 1 The participants were
asked which of the four alternatives:
hair washing, feeding, changing dia-
pers and tooth brushing was, in their
experience, the most troublesome to
help a patient/resident with. The
results are given in per cent of all
answers. N = 413.
0
10
20
30
40
50
60
70
80
Rather dont want
to do it
Dont have enough
with time
The elderly manage
by themselves
The residents
dont cooperate
Figure 2 The participants were
asked which of the four alternatives,
dont want to do it, dont have
enough time, the residents manage
by themselves, the residents dont
cooperate, was the greatest obstacle
to giving help with oral health care.
The results are given in per cent of all
answers. N = 444.
2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787e792
Attitudes to and knowledge about oral health care e789
The fourth category was Need of improved nursing
home personnel cooperation:
The nursing staff ought to be present when the oral
health care assessments are performed on the elderly.
The fth category was Lack of nursing home per-
sonnel empathy:
Its pure laziness from the staff not to brush the teeth
of the elderly, and when there isnt time. Imagine not
to have your teeth brushed! You will always start with
yourself.
Discussion
Many efforts have been made worldwide to
improve oral health care in nursing.
12
The Swedish
dental remuneration reform is one such effort, but
its effects have not been evaluated. One of the aims
of the Swedish dental reform was to support the
nursing home personnel with knowledge and
motivation to perform oral health care to improve
the quality of life and nutrition of the elderly. This
is secured through both theoretical and practical
training. The training sessions are offered free of
charge to the nursing home personnel by a dental
team paid by the local government, but it is the
responsibility of the nursing home managers to
arrange for their staff to attend.
As regards the dropout rate, other studies in
similar contexts have shown a response rate
somewhere between 25
13
and 75%
14
of the sam-
ple. The dropout rate in the present study was
28%. It may be difcult to obtain a higher rate,
because of staff turnover, sick leave and working
schedules. There are probably also individuals who
decline to participate in ways that might skew the
result in a somewhat more positive direction. Free
comments, given by only 16% of the participants,
were probably also made by those with the greatest
interest in oral health care.
Although 95% of the respondents had worked at
nursing homes for more than 2 years, more than
one-third had not received any oral health care
training. Studies from other countries have shown
that between 39 and 45.3%
15,16
of nursing home
personnel have been trained to perform oral health
care on their patients. Despite the system of offer-
ing oral health care training to all nursing home
personnel, the responsibility for ensuring that they
attend is still with the nursing home managers.
Often, temporary staff members are not allowed to
attend the training sessions, and disturbances in the
daily working plan is another reason for not
allowing participation. One explanation for this
could be high workloads.
10
There were only a few registered nurses partici-
pating in the present study. Although there are not
many registered nurses in Swedish elderly care,
their participation is very important as they are
responsible for the nursing work, despite the fact
that they are seldom involved in the practical
handling of the tasks,
10
and they serve as managers
for the other nursing home personnel. It has been
reported that the registered nurses sometimes
consider oral health care as the responsibility of the
dental profession,
17
but the present study does not
support such ndings. We were unable to draw
conclusions about this owing to the small number
of participating registered nurses.
Although nursing home personnel consider oral
health care to be a part of good nursing, as sup-
ported in other studies,
16,18
it has low priority in
the daily work.
10
The majority of the nursing
home personnel in this study regarded tooth
brushing as the most troublesome nursing activity
and stated that the greatest obstacle to not giving
oral health care was that the elderly residents
were not cooperative, which has been highlighted
many times before.
9,18,19
Thus, although so many
of the staff members found tooth brushing dif-
cult, only 25% thought that help from the dental
team would improve the oral health care. Perhaps,
the nursing home personnel did not have con-
dence in the ability of the dental staff to handle
uncooperative residents or perhaps, they were
aware of their own professional nursing respon-
sibility for the daily care. Many were of the
opinion that the elderly themselves spoke up
when they needed help with their oral health
care. Could this be an excuse for not performing
0
10
20
30
40
50
60
Doubtful Dont agree Agree
Figure 3 The participants were asked to give one of the
three alternative answers: doubtful, dont agree and
agree, to the statement: Even if you take good care of
your teeth, they will fall out when you get older. The
results are given in per cent of all answers. N = 454.
2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787e792
e790 I. Wa rdh et al.
oral health care for uncooperative elderly resi-
dents? Dental fear among the nursing home per-
sonnel may be another reason.
9
The nursing home personnels view of oral
health care has been described as inuential both
in terms of the value set on oral health and the
performance of oral health care at a nursing
home.
20
Oral health care education has been
shown to improve both the nursing home person-
nels attitudes towards and knowledge of oral
health care.
2123
Training may, thus, lead to
improved performance, but there is very little
research discussing the effects of such training.
21
Paulsson et al.
24
showed that 3 months after oral
health care training, the nursing home personnels
self-reported skills in performing oral health care
on their patients had improved, but studies have
failed to show any effect on the patients oral
health/oral hygiene.
25
What kind of oral health training is of interest to
the nursing home personnel and will result in
better oral health care for dependent individuals?
Some authors have pointed out the value of con-
tinuous support and supervision in oral health care,
especially when dealing with elderly individuals
with dementia,
26
but the present study did not give
much support to practical oral health care training
as the best way of improving oral health care.
Although many of the respondents in the present
study had regular dental care themselves, many
were also of the opinion that a persons teeth will
fall out as they become older. It may be difcult for
people to push for oral health care, if they think it is
meaningless in the long run. Other studies also
show that about 50% of nursing home personnel
had the misconception that tooth loss is a natural
process.
16,21
What effects does this opinion have on
oral health? Is there a need of supplementary
assistance, for instance from municipal dental
hygienists?
Conclusions
The results of the study indicate that the nursing
home personnel have a generally positive attitude
towards oral health care, but when it comes to
implementation and knowledge, there are needs
for improvements.
It is important that oral health care education is
available to and made of interest for all nursing
home staff. In addition, it is possible that in the
nursing home context for the elderly of today,
nursing home personnel cannot handle the daily
oral health care alone, but need assistance from, for
example, municipal dental hygienists.
Acknowledgements
We thank all the nursing home personnel who
enabled us to complete this project and dental
hygienists Fayezeh Shams Nejad and Linda Stens-
tro m as well as language reviewer Linda Schenck.
The study was nancially supported by the
Jo nko ping County Council.
References
1. United Nations Population Division. World Pop-
ulation Prospects: The 2002 Revision. New York, NY,
USA: United Nations, 2003.
2. HugosonA, KochG, Go thbergCet al. Oral healthof
individuals aged 380 years in Jo nko ping, Sweden,
during 30 years (19732003). II. Reviewof clinical and
radiographic ndings. Swed Dent J 2005; 29: 139155.
3. Samson H, Vesterhus Strand G, Haugejorden O.
Change in oral health status among the institution-
alized Norwegian elderly over a period of 16 years.
Acta Odont Scand 2008; 66: 368373.
4. Holme n A, Stro mberg E, Hagman Gustafsson M-
L, Wa rdh I, Gabre P. Oral status in home-dwelling
elderly dependent on moderate or substantial sup-
portive care for daily living: prevalence of edentulous
subjects, caries and periodontal disease. Gerodontology
doi: 10.1111/j.1741-2358.2011.00507.x.
5. Kandelman D, Petersen PE, Ueda H. Oral health,
general health, and quality of life in older people. Spec
Care Dentist 2008; 28: 224236.
6. Petersen PE. Global policy for improvement of oral
health in the 21st century implications to oral
health research of World Health Assembly 2007,
World Health Organization. Community Dent Oral
Epidemiol 2009; 37: 18.
7. The National Board of Health and Welfare.
A

ndring av tandva rdslagen. (In Swedish). Stockholm:

SFS, 1998: 554.
8. The National Board of Health and Welfare. Sa r-
skild tandva rdsforordning. (In Swedish). Stockholm: SFS,
1998: 1338.
9. Wa rdh I, Anderson L, So rensen S. Staff attitudes
to oral health care. A comparative study of registered
nurses, nursing assistants and home care aides.
Gerodontology 1997; 14: 2832.
10. Wa rdh I, So rensen S. Development of an index to
measure oral health care priority among nursing staff.
Gerodontology 2005; 22: 8490.
11. Graneheim UH, Lundman B. Qualitative content
analysis in nursing research: concepts, procedures
and measures to achieve trustworthiness. Nurse Educ
Today 2004; 24(2): 105112. Review.
12. Krippendorff K. Content Analysis: An Introduction to
its Methodology. Beverly Hills, CA: Sage, 1980.
13. White R. Nurse assessment of oral health: a review of
practice and education. Br J Nurs 2000; 9: 260266.
14. Costello T, Coyne I. Nurses knowledge of mouth
care practices. Br J Nurs 2008; 17: 264268.
2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787e792
Attitudes to and knowledge about oral health care e791
15. Dharamsi S, Jivani K, Dean C, Wyatt C. Oral care
for frail elders: knowledge, attitudes, and practices of
long-term care staff. J Dent Educ 2009; 73: 581588.
16. Sumi Y, Nakamura Y, Nagaosa S, Michiwaki Y,
Nagaya M. Attitudes to oral care among caregivers in
Japanese nursing homes. Gerodontology 2001; 18: 26.
17. Thean H, Wong ML, Koh H. The dental awareness
of nursing home staff in Singapore a pilot study.
Gerodontology 2007; 24: 5863.
18. Andersson K, Nordenram G, Wa rdh I, Berglund
B. The district nurses perceptions of elderly patients
oral health: a qualitative interview study. Acta Odontol
Scand 2007; 65: 177182.
19. Frenkel HF. Behind the screens: care staff observa-
tions on delivery of oral health care in nursing homes.
Gerodontology 1999; 16: 7580.
20. Dolan TA, Atchison KA. Implications of access,
utilization and need for oral health care by the non-
institutionalized and institutionalized elderly on the
dental delivery system. J Dent Educ 1993; 57: 876
887.
21. Paulsson G, So derfeldt B, Nederfors T, Fridlund
B. Nursing personnels view on oral health from a
health promotion perspective: a grounded theory
analysis. Acta Odontol Scand 2002; 60: 4249.
22. Frenkel HF, Harvey I, Needs KM. Oral health care
education and its effect on caregivers knowledge and
attitudes: a randomised controlled trial. Community
Dent Oral Epidemiol 2002; 30: 91100.
23. Reed R, Broder HL, Jenkins G, Spivack E, Janal
MN. Oral health promotion among older persons and
their care providers in a nursing home facility.
Gerodontology 2006; 23: 7378.
24. Wa rdh I, Berggren U, Hallberg LRM, Andersson
L, So rensen S. Dental auscultation for nursing per-
sonnel as a model of oral health care education:
development, baseline, and 6 month follow up
assessments. Acta Odontol Scand 2002; 60: 1319.
25. Paulsson G, Fridlund B, So derfeldt B, Nederfors
T. Recall of an oral health education programme by
nursing personnel in special housing facilities for the
elderly. Gerodontology 2001; 18: 714.
26. MacEntee MI, Wyatt CCL, Beattie BL et al. Pro-
vision of mouth-care in long-term care facilities: an
educational trial. Community Dent Oral Epidemiol 2007;
35: 2534.
Correspondence to:
Inger Wa rdh, Karolinska Institutet, Department of
Dental Medicine, PO Box 4064, SE-141 04 Hudd-
inge, Sweden.
Tel.: +46 8 524 882 26
E-mail: inger.wardh@ki.se
2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787e792
e792 I. Wa rdh et al.